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New York State
Workers' Compensation Board
OFFICE OF CONTINUOUS IMPROVEMENT
328 State Street  Schenectady, New York 12305
Andrew M. Cuomo
Governor



Subject No. 046-1.16

New And Revised Workers' Compensation Board Forms

1-1-11 through 1-31-12

Date: March 19, 2012

The table below shows Workers' Compensation Board forms that have been recently issued or revised. Most of these forms are available on the Board's website (www.wcb.ny.gov) under the heading Forms. For information on any Board form, contact the Board's Forms Department at FormsDepartment@wcb.ny.gov.

While most of these forms have been updated simply to reflect the new Buffalo mailing address, the following forms contain these substantive changes:

  • C-4.3 was modified to accommodate the 2012 Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity.
  • PH-16.2 was modified to accommodate implementation of the 2010 New York State Construction Industry Fair Play Act (Labor Law § 861).
  • RFA-1LC and RFA-2 were reorganized to allow parties to identify the issue involved and to instruct parties as to what evidence is required for further development of the issue.
  • SI-10.1 was updated to reflect cumulative compensation payments through 9/30/11.
  • VDF-1 was created to accommodate the 2012 Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity.
  • W-32R was updated to reflect changes within the Board's WAMO office.

Forms Department

 

Recently Issued or Revised Workers' Compensation Board Forms
1-1-11 through 1-31-12
FORM NO. TITLE DATE
ADR-1 Alternative Dispute Resolution Program Report of Injury Jan-11
ADR-1.1 Modification of Previous Report Jan-11
ADR-2 Alternative Dispute Resolution Program Final Disposition on Settlement of Claim Jan-11
AFF-1 Affidavit for Death Benefits Jan-11
C-105 Notice of Compliance - Workers' Compensation Law Jan-11
C-11 Employer's Report of Injured Employee's Change in Work Status Resulting from Injury Jan-11
C-121 Claim for Compensation and Notice of Commencement of Third Party Action Jan-11
C-18.6 Information to Claimant Under Section 15, Subd. 3 Jan-11
C-2.0 Employer's Report of Work-Related Injury/Illness Jan-11
C-21 Application for an Advance on Periodic Payments of Compensation Jan-11
C-22 Application for Approval of Non-Schedule Adjustment Jan-11
C-240 Employer's Statement of Wage Earnings Jan-11
C-25 Application for Reopening of Claim More Than Seven Years After Accident Jan-11
C-251.3 Notice of Right to Reimbursement of Compensation Payments Under Section 14(6) & Section 15(8) Jan-11
C-27 Medical Proof of Change in Condition in Support of Application for Reopening of Claim Jan-11
C-3.0 Employee's Claim for Compensation Jan-11
C-32.1 Settlement Agreement - Section 32 - Claimant Release Jan-11
C-3S Spanish Employee's Claim for Compensation Jan-11
C-4 AMR Ancillary Medical Report Jan-11
C-4 AUTH Attending Doctor's Request for Authorization and Carrier's Response Jan-11
C-4.0 Attending Doctor's Report and Carrier/Employer Billing Form Jan-11
C-4.2 Doctor's Progress Report Jan-11
C-4.3 Doctor's Report of MMI/Permanent Impairment Jan-12
C-430S Statement of Rights Jan-11
C-5 Attending Ophthalmologist's Report Jan-11
C-62 Claim for Compensation in a Death Case Jan-11
C-64 Proof of Death Jan-11
C-65 Proof of Burial and Funeral Expenses - by Undertaker Jan-11
C-669 Notice to Chair of Carrier's Action on Claim for Benefits Jan-11
C-7.0 Notice That Right to Compensation is Controverted Jan-11
C-8.1 Notice of Treatment Issue(s)/Disputed Bill Issue(s) Jan-11
C-8.4 Notice to Health Care Provider and Injured Worker of a Carrier's Refusal to Pay All (Or A Portion Of) a Medical Bill Due to Valuation Objection(s) Jan-11
C-8/8.6 Notice to Chair that Payment of Compensation Has Been Stopped or Modified Jan-11
DB-120 Notice of Compliance - Disability Benefits Law Jan-11
DB-271S Statement of Rights - Disability Benefits Law Jan-11
DB-470 Preliminary Claim for Reimbursement of Benefits Paid Under the NYS DBL Jan-11
DC-120 Discharge or Discrimination Complaint Jan-11
FCE-4 Practitioner's Report of Functional Capacity Evaluation Jan-11
IME-3 Practitioner's Report of Request for Information/Response to Request for Information Regarding Independent Medical Examination Jan-11
IME-4 Practitioner's Report of Independent Medical Examination Jan-11
IME-5 Claimant's Notice of Independent Medical Examination under Section 137 WCL Jan-11
MD-1 Attending Doctor's Request for Medical Authorization Determination Jan-11
MD-3 Carrier/Self-Insurer's Objection to Attending Doctor's Request for Medical Authorization Determination Jan-11
MG-1 Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response Jan-11
MG-2 Attending Doctor's Request for Approval of Variance and Carrier's Response Jan-11
MR-4 Impartial Specialist's Report of Medical Records Review Jan-11
OC-110A Claimant's Authorization to Disclose Workers' Compensation Records Jan-11
OC-110AS Claimant's Authorization to Disclose Workers' Compensation Records - Spanish Version Jan-11
OC-400 Notice of Retainer and Appearance/Substitution and Appearance Jan-11
OC-400.1 Application for a Fee by Claimant's Attorney or Representative Jan-11
OC-923 Letter to New Employer Re W.C. and D.B. Coverage Jan-11
OT/PT-4 Occupational/Physical Therapist's Report Jan-11
PH-16.2 Pre-Hearing Conference Statement Feb-11
PS-4 Psychologist's Report Jan-11
RB-89 Cover Sheet - Application for Board Review Jan-11
RB-89.1 Cover Sheet - Rebuttal of Application for Board Review Jan-11
RB-89.2 Cover Sheet - Application for Full Board Review Jan-11
RB-89.3 Cover Sheet - Rebuttal of Application for Full Board Review Jan-11
RFA-1LC Request for Further Action by Legal Counsel May-11
RFA-1W Request for Assistance by Injured Worker Jan-11
RFA-2 Carrier's/Employer's Request for Further Action May-11
SI-10.1 Report of Cumulative Compensation Payments Sep-11
VAW-105 Notice of Compliance - Volunteer Ambulance Workers' Law Jan-11
VAW-2 Political Subdivision's Report of Injury to Volunteer Ambulance Worker Jan-11
VAW-3 Volunteer Ambulance Worker's Claim for Benefits Jan-11
VAW-62 Claim for Volunteer Ambulance Workers' Benefits in a Death Case Jan-11
VDF-1 Loss of Wage Earning Capacity, Vocational Data Form Jan-12
VF/VAW-11C Volunteer's Notification of Executive Officer of Fire/Ambulance Company of Significant Risk of Transmission of HIV Under Sec. 11-C(1) VFBL/VAWBL Jan-11
VF/VAW-305 Letter re: Injured in the Line of Duty Jan-11
VF-105 Notice of Compliance - Volunteer Firefighters Benefit Law Jan-11
VF-2 Political Subdivision's Report of Injury to Volunteer Firefighter Jan-11
VF-3 Volunteer Firefighter's Claim for Benefits Jan-11
VF-62 Volunteer Firefighter's Claim for Compensation in a Death Case Jan-11
W-32R WAMO Settlement Agreement - Section 32 WCL Mar-11
WTC-12 Registration of Participation in World Trade Center Rescue, Recovery and/or Clean-Up Operations Jan-11